The Toddler/Preschool Child
Case 3.1 Earache
Clinical Case Studies for the Family Nurse Practitioner, First Edition. Edited by Leslie Neal-Boylan.
© 2011 John Wiley & Sons, Inc. Published 2011 by John Wiley & Sons, Inc.
59
SUBJECTIVE
Julie, a 3 - year - old preschool child, presents to the offi ce with a complaint of left ear pain for 2 days.
She is accompanied by her mother, Mary. She has had an intermittent fever and her maximum tem- perature at home was 101 ° F (axillary). The pain is worse sometimes when she is lying down. The pain is occasionally relieved with the use of over - the - counter pain relievers. Julia has had no vomit- ing or diarrhea. She has had a slight runny nose, but no cough.
Diet: Julia ’ s nutrition history reveals that she has a balanced diet with enough dairy, protein, fruits, and vegetables. Her appetite has decreased over the past 2 days since the ear pain began.
Elimination: She is voiding well with no complaints of dysuria.
Sleep: Julia sleeps approximately 10 hours at night and takes one 1 - hour nap at her preschool. She usually has no problems falling or staying asleep but since the ear pain has started, her sleep has been interrupted.
Past m edical h istory: Julia was born via vaginal delivery at 40 weeks ’ gestation. Since being dis- charged at 2 days of age, she has had no emergency department ( ED ) visits or hospitalizations. Julia has had 2 episodes of otitis media that were cleared with antibiotics. She has had no injuries or ill- nesses since that time. Julia passed her developmental screening at her last well - child visit. She cur- rently attends preschool and is doing well according to Mary. She has no chronic illnesses and is currently taking no medications.
Social h istory: Julia lives at home with both parents. Her mother works as a teacher, and her father is a commercial fi sherman. The family has a pet cat. Julia ’ s father smokes, but not in the home.
Family m edical h istory: Julia ’ s mother (31 years old) and father (30 years old) are healthy and have no history of chronic medical conditions. Her maternal grandmother (age 52 years) has a history of lupus. Her maternal grandfather (54 years of age) has a history of prostate cancer (in remission).
Julia ’ s paternal grandfather (age 59 years) has a history of hypertension. Her paternal grandmother (53 years of age) has a history of asthma.
By Mikki Meadows - Oliver , PhD, RN and Susannah Young, MSN, RN
60 The Toddler/Preschool Child
Medications: Julia is currently taking no prescription or herbal medications. She has been taking over - the - counter pain relievers/antipyretics to relieve symptoms associated with ear pain. Julia has an allergy to penicillin. She gets hives when she takes penicillin. Julia has no known allergies to food or the environment. She is up to date on required immunizations.
OBJECTIVE
Julia ’ s vital signs are taken, and her weight in the offi ce today is 14 kg. Her temperature is slightly elevated at 38 ° C (temporal). Julia is alert and quiet, sitting in her mother ’ s lap. She appears well hydrated and well nourished.
Skin: Her skin is clear of lesions and warm to touch. There is no cyanosis of her skin, lips, or nails.
There is no diaphoresis noted. Julia has good skin turgor on examination.
HEENT : Julia ’ s head is normocephalic. Her red refl exes are present bilaterally; and her pupils are equal, round, and reactive to light. There is no ocular discharge noted. Julia ’ s external ear reveals that the pinnae are normal, and there is no tenderness to touch on the external ear. On otoscopic examina- tion, the right tympanic membrane (TM) is gray, in normal position, with positive light refl exes. Bony landmarks are visible, and there is no fl uid noted behind the TM. The left TM is erythematous and bulging with purulent fl uid visible behind the TM. The TM is opaque with no light refl ex or bony landmarks present. Both nostrils are patent. There is no nasal discharge, and there is no nasal fl aring.
Julia ’ s mucous membranes are noted to be moist. She has 20 teeth present without evidence of caries.
There are no lesions present in the oral cavity.
Neck: Julia ’ s neck is supple and able to move in all directions without resistance. There are shotty anterior cervical nodes present on the left side of the neck. There is no erythema or tenderness of the nodes.
Respiratory: Julia ’ s respiratory rate is 26 breaths per minute and her lungs are clear to auscultation in all lobes. There is good air entry, and no retractions or grunting are noted on examination. No deformities of the thoracic cage are noted.
Cardiovascular: Julia ’ s heart rate is 102 beats per minute with a regular rhythm. There is no murmur noted upon auscultation.
Abdomen: Normoactive bowel sounds are present throughout. Julia ’ s abdomen is soft and non- tender. There is no evidence of hepatosplenomegaly.
Genitourinary: Genitourinary examination reveals normal female genitalia.
Neuromusculoskeletal: Julia is noted to have good tone in all extremities. She has full range of motion of all extremities. Her extremities are warm and well perfused. Capillary refi ll is less than 2 seconds, and her spine is straight.
CRITICAL THINKING
Are there laboratory tests or diagnostic imaging studies that should be ordered as part of a workup for ear pain?
What is the most likely differential diagnosis and why?
What is the plan of treatment, referral, and follow - up care?
Does this patient ’ s psychosocial history affect how you might treat this case?
What if the patient lived in a rural setting?
Earache 61
Are there any demographic characteristics that might affect this case?
Are there any standardized guidelines that you should use to assess or treat this case?
RESOLUTION
Diagnostic t ests: Middle ear effusion may be confi rmed with the observation of decreased or absent tympanic membrane mobility with pneumatic otoscopy. Unfortunately, when performing pneumatic otoscopy in infants and young children, it can be very diffi cult to maintain a tight fi tting seal for the exam. Tympanometry may be performed to determine the presence of fl uid (infected or uninfected) in the middle ear. Tympanometry is useful if cerumen makes visualization of the tympanic membrane diffi cult on otoscopic exam. Tympanocentesis, though not often done, may be performed to acquire a sample of the fl uid behind the tympanic membrane for culture and sensitivity if the child is immu- nocompromised or has failed previous courses of antibiotic therapy.
What is the most likely differential diagnosis and why?
Otitis media:
The complaint of ear pain can lead to several differential diagnoses. Acute otitis media, otitis externa, cholesteatoma, foreign body, and hemotympanum (blood behind the tympanic membrane) are some of the more common causes of ear pain in a child. A thorough history and careful physical exam will help to differentiate among these diagnoses.
Otitis media is the most likely diagnosis for Julia based on the history and physical examination fi ndings. Julia had a fever, sleep and eating disturbances, and a previous history of otitis media. On examination, the left TM was erythematous and bulging. It is unlikely to be otitis externa as there is no ear pain elicited by palpation of the external ear, a characteristic sign of otitis externa. Cholesteatoma should be considered in the differential because of Julia ’ s past diagnosis of otitis media. However, there was no pocket of retraction, keratinous debris, or mass on the tympanic membrane, ruling out a diagnosis of cholesteatoma.
What is the plan of treatment, referral, and follow - up care?
The fi rst line treatment for uncomplicated otitis media in a child with a temperature less than 39 ° C (102.2 ° F) is amoxicillin, 80 – 90 mg/kg per day for 10 days. For children 6 years and older, a 5 – 7 day course of amoxicillin is appropriate. For children with a temperature over 39 ° C (102.2 ° F) or if H.
Infl uenza or M. Catarrhalis are suspected, therapy should start with amoxicillin - clavulanate, (90 mg/
kg per day of amoxicillin and 6.4 mg/kg per day of clavulanate) in 2 divided doses per day.
In patients with non – Type 1 allergic reactions to amoxicillin, a cephalosporin may be used (cefdinir 14 mg/kg per day in 1 or 2 doses, cefpodoxime 10 mg/kg per day once daily or cefuroxime 30 mg/
kg per day in 2 divided doses). If the child has experienced a Type 1 reaction in the past (anaphylaxis or urticaria), azithromycin (10 mg/kg per day on the fi rst day, then 5 mg/kg for 4 days) or clarithro- mycin (15 mg/kg per day in 2 divided doses) may be used. Because Julia has had hives in the past when using penicillin, azithromycin is the best choice for her. At 14 kg, her dose on day 1 would be 140 mg and on days 2 through 5, her dose would be 70 mg. Using the 100 mg/5 mL oral suspension, she would be instructed to take 7 mL on day 1, then 3.5 mL for days 2 through 5.
Based on the history and physical exam fi ndings, no referrals are needed at this time.
Julia ’ s mother, Mary, should be instructed to follow up with a call to the offi ce or to seek medical attention if no improvement is seen in 48 – 72 hours after the fi rst dose of medication. Julia ’ s fever should be lowered, and her sleeping and eating should also improve in 48 – 72 hours.
Does this patient ’ s psychosocial history affect how you might treat this case?
Julia ’ s psychosocial history contains elements that may increase her risk for developing otitis media.
Her enrollment in a child care center places her at an increased risk for developing otitis media. Julia ’ s father is a smoker. Exposure to passive cigarette smoke has been found to be a risk factor for the development of otitis media in preschool children. This information can be discussed with Julia ’ s parents. Julia ’ s father can be given information on smoking cessation resources.
62 The Toddler/Preschool Child
What if the patient lived in a rural setting?
If Julia lived in a rural setting, her parents should be given clear instructions about when and how to follow up if there is no improvement in the 48 – 72 hour window or if symptoms worsen. If an emergency department is not easily accessible, Julia should be followed closely by her primary care provider to ensure that worsening symptoms are not left unnoticed.
Are there any demographic characteristics that might affect this case?
Otitis media has been found to be more frequent in certain racial groups, such as the Inuit and American Indians. The difference in the frequency of occurrence compared to other racial groups is likely due to anatomic differences in the eustachian tube. Regarding gender, boys have been found to be affected more commonly than girls. No specifi c causative factors for this have been found in the literature. Age is a demographic characteristic that affects otitis media. Otitis media occurs more commonly in infants, toddlers, and preschool children between the ages of 6 months and 3 years of age. This age distribution may be due to a combination of several factors. These factors can be immu- nologic, such as lack of pneumococcal antibodies, and/or anatomic. Younger children have a low angle of the eustachian tube with relation to the nasopharynx.
Are there any standardized guidelines that you should use to assess or treat this case?
The American Academy of Pediatrics and American Academy of Family Physicians have developed clinical practice guidelines for the management of otitis media (Liberthal, Ganiats, et al., 2004).
REFERENCES AND RESOURCES
Bellussi , L. , & Mandala , M. ( 2005 ). Quality of life and psycho - social development in children with otitis media with effusion . Acta Otorhinolaryngologica Italica , 25 ( 6 ), 359 – 364 .
Greenberg , D. , Hoffman , S. , Leibovitz , E. , & Dagan , R. ( 2008 ). Acute otitis media in children: Association with day care centers — Antibacterial resistance, treatment, and prevention . Paediatric Drugs , 10 , 75 – 83 .
Hughes , E. , & Lee , J. ( 2001 ). Otitis externa . Pediatrics in Review , 22 , 191 – 197 .
Liberthal , A. , Ganiats , T. , et al. ( 2004 ). Diagnosis and management of acute otitis media: Clinical practice guide- line . Pediatrics , 113 ( 5 ), 1451 – 1465 .
Nguyen , C. , & Parikh , S. ( 2008 ). Cholesteatoma: In brief . Pediatrics in Review , 29 ( 9 ), 330 – 331 .
Sophia , A. , Isaac , R. , Rebekah , G. , Brahmadathan , K. , & Rupa , V. ( 2010 ). Risk factors for otitis media among preschool, rural Indian children . International Journal of Pediatric Otorhinolaryngology , 74 , 677 – 683 .